[104-10222-10040.pdf — page 70]
# DESIGNATION OF BENEFICIARFEDERAL EMPLOYEES' GROUP LIFEINSURANCE ACT OF 1954INFORMATION CONCERNING THE INSURED:NAME (Last) ROBERT (First) TYLER (Middle) DATE OF BIRTH (Month, day, year)SHAW JUNE 18 1925PLACE AN "X" IN THE APPROPRIATE BOX BELOW TO SHOW WHETHER YOU ARE:* AN EMPLOYEE  RETIRED OR AN APPLICANT FOR RETIREMENT  RECEIVING FEDERAL EMPLOYEE COMPENSATION BENEFITS OR AN APPLICANT FOR SUCH BENEFITSIF YOU ARE RETIRED OR RECEIVING FEDERAL EMPLOYEE COMPENSATION GIVE. YOUR "CSA","CSI" or "X" NUMBERDEPARTMENT OR AGENCY IN WHICH LAST EMPLOYED (If retired, former department or agency):DEPT. OF STATE (Department of agency) ARA (Bureau) WASH 25 D.C. (Location-City and State)(Division)IMPORTANTRead instructions on back of duplicate before filling in this formI, the individual identified above, canceling any and all previous Designations of Beneficiary under the Federal Employees' Group Life Insurance Act heretofore made by me, do now designate the beneficiary or beneficiaries named below to receive any amount of GROUP LIFE INSURANCE and GROUP ACCIDENTAL DEATH INSURANCE due and payable at my death, I understand that this Designation of Beneficiary will remain in full force and effect, with respect to any amount payable, unless or until canceled by me in writing, or until such time as it is automatically canceled (see regulation "f" on reverse side of duplicate-copy).INFORMATION CONCERNING THE BENEFICIARY OR BENEFICIARIES:| True or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || JANET LEE SNAW                                                              | 909 N. CAMPBELL AVE. TUCSON, ARIZONA      | WIFE         | ALL                                  ||                                                                             |                                           |              |                                      ||                                                                             |                                           |              |                                      ||                                                                             |                                           |              |                                      ||                                                                             |                                           |              |                                      ||                                                                             |                                           |              |                                      |I hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share of any deceased beneficiary who may predecease me shall be distributed equally among the surviving beneficiaries, or entirely to the survivor. I understand that this Designation of Beneficiary shall be void if none of the designated beneficiaries is living at the time of my death. I hereby specifically reserve the right to cancel or change any Designation of Beneficiary at any time without knowledge or consent of the beneficiary.Mar 27 1963(Date of execution--month, day, year)Robert T Shaw(Signature of Insured)WITNESSES TO SIGNATURE (A witness is ineligible to receive payment as a beneficiary):(Signature of witness) 1114 Ellen Ave Falls Church(Number and street) (City, zone number, and State)(Signature of witness) (Number and street) (City, zone number, and State)PRINT OR TYPE NAME AND ADDRESS OF INSUREDRobert T Shaw909 Campbell Ave.Tucson, Ariz.THIS SPACE RESERVED FOR RECEIVING AGENCYPER/EMDMAR 27 1963SEE REVERSE SIDE OF DUPLICATE COPY FOR INSTRUCTIONS ON WHERE TO FILE THESE FORMS. DO NOT FILE WITH THE OFFICE OF FEDERAL EMPLOYEES' GROUP LIFE INSURANCE.